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Waste Tire Su. y & Inspection Reportenspection Report Number <br /> Li State CIWMB California I 1 - 10 8 8 2 6 3 <br /> grated 1st(New <br /> Manage Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> '3art A- Survey BLUE OR BLACK INK PEN <br /> tipsiness Profile jl inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 11 1 Q Routine Q Re-inspection Q Referral Q Observation <br /> Local !J If Referral,choose referral type(Fill one) <br /> Identifier: �' .: ! i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street - Inspection Date <br /> X1 <br /> / <br /> I �� <br /> State ZIP Code Time In Time Out <br /> Business Rep Title �} 1 O AM Q AM <br /> V { 0 P QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fillone only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> 6Closed Altered <br /> GPS Latitude i I , I I I ® Q Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude — ! i Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that ap y - <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> —-- - Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § j D f } <br /> Comments i t V io 0Yl <br /> 1`> t�11 . — ( ! `'. Vic./ `7 <br /> Cf <br /> Inspection Form Included: Q <br /> Comments Included. Q Busine 's Signature' , <br /> Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X "Y ,/ !E XI A MIP; � I EI 11,12131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />